MONTGOMERY COUNTY CLERK/RECORDER

#1 COURTHOUSE SQUARE
P.O. BOX 595
HILLSBORO, IL 62049
Phone: (217) 532-9530 Email: sandyleitheiser@hotmail.com

GUIDELINES FOR USING THE MONTGOMERY COUNTY, IL

ABSENTEE BALLOT APPLICATION FORM
FOR REGISTERED VOTERS

A qualified voter may make application by mail, not more than 40 days nor less than 5
days prior to the date of the election for an official ballot for the voter’s precinct, to be
voted at such election. For the November 2nd, 2010 General Election, applications may be
filed with the proper Election Authority between September 23rd and October 28th, 2010.

Due to a recent change in Election Law, a blank Absentee Ballot Application form is
now available. Voters may type or print their information on this new form, and sign the
form where indicated. All entries must be legible for the voter’s application to be
processed.

Once the Absentee Ballot Application form is completed, signed and dated, it may be
returned to the Montgomery County Clerk’s office either by the voter in person, by mail, or
via a third party. Ballots can only be issued by mail to qualified registered voters whose
application is received by October 28th, 2010.

IMPORTANT NOTICE TO VOTER

Although blank Absentee Ballot Application forms are now available, you are not
required to use them and may continue to phone or email the Montgomery County Clerk’s
office for a personalized Absentee Ballot Application to be mailed to you as we have done
in the past. Those voters making such requests have the opportunity to confirm that their
voter registration is current and correct, and personalized Absentee Ballot Applications
already will have much of the needed information pre-printed for your convenience.

When applying with the blank Absentee Ballot Application, please provide a current
daytime phone number and/or an e-mail address where you can be reached which allows us
to contact you should your application be incomplete, if there is a problem with your
registration, or if your ballot is returned by the post office as undeliverable.

IMPORTANT NOTICE TO CIRCULATORS

If you are distributing blank Absentee Ballot Application forms, be sure to confirm
that the applicant is a Registered Voter, that all fields are completed and legible-
including the important Voter Phone/e-mail Contact Information, and make sure you
return all completed applications to the correct Election Authority within the time frame
allowed by Law.
ABSENTEE BALLOT APPLICATION FORM revised 8/2010

When completed, deliver to

Montgomery County Clerk
# 1 Courthouse Square, PO Box 595
Hillsboro, IL 62049
Phone: 217-532-9530

1. NAME Last Name First Name Middle Name Suffix

Street Address (include apt, lot, etc, if applicable)

City State ZIP Daytime Phone/E-mail

2. BIRTH YEAR ONLY FORMER NAME (if applicable)

3. ADDRESS TO WHICH BALLOT IS TO BE MAILED

Street Address (include apt, lot, etc.) AND P.O. Box # (if applicable)

City State ZIP Country (other than USA)

For PRIMARY ELECTIONS ONLY – PARTY AFFILIATION (Check One Box Only)
Republican Green Democratic Non-Partisan Other ______________________

I state that I am a resident in the precinct and residence as stated above, that I have lived at such address for 30 or more days preceding
the election, that I am lawfully entitled to vote in such precinct at said election to be held therein and that I wish to vote by absentee ballot.

I hereby make application for an official ballot or ballots to be voted by me at such election, and I agree that I shall return such ballot or
ballots to the official issuing the same prior to the closing of the polls on the date of the election or, if returned by mail, postmarked no
later than midnight preceding election day, for counting no later than during the period for counting provisional ballots, the last day of
which is the 14th day following election day.

Under penalties as provided by law pursuant to Section 29-10 of the Election Code, the undersigned certifies that the statements
Set forth in this application are true and correct.

X_______________________________________________________ Dated : ________________________

(10 ILCS 5/29-10) (from Ch. 46, par. 29-10)
Sec. 29-10. Perjury. (a) Any person who makes a false statement, material to the issue or point in question, which he does not believe
to be true, in any affidavit, certificate or sworn oral declaration required by any provision of this Code shall be guilty of a Class 3 felony.
(b) Any person who is convicted of violating this Section shall be ineligible for public employment for a period of 5 years immediately
following the completion of his sentence. For the purpose of this subsection, "public employment" shall mean any elected or appointed
office created by the Constitution or laws of this State, or any ordinance of a unit of local government. "Public employment" shall also
include any position as an employee of the State of Illinois, or a unit of local government or school district.
(Source: P.A. 83-1097.)

Any person who knowingly solicits you to falsify your eligibility to cast an absentee ballot is guilty of a Class 3 felony

(10 ILCS 5/19-2) (from Ch. 46, par. 19-2)

Sec. 19-2. Any elector as defined in Section 19-1 may by mail, not more than 40 nor less than 5 days
prior to the date of such election, or by personal delivery not more than 40 nor less than one day
prior to the date of such election, make application to the county clerk or to the Board of Election
Commissioners for an official ballot for the voter's precinct to be voted at such election.
(Source: P.A. 95-440, eff. 8-27-07; 96-553, eff. 8-17-09.

Notice To Absentee Applicants:

The first day an absentee ballot may be issued for the November 2, 2010 General Election is September
23, 2010. The last day that a ballot can be mailed to you is October 28, 2010. If you wish to
receive your ballot by mail, your application must be filed in the office of your County Clerk or
Board of Election Commissioners on or between these two dates. If you have any questions regarding
this application or the absentee voting process, contact the Election Authority indicated in the
upper left corner of this application.